Subclinical-hypothyroidism: a pathology in evolution

Subclinical-hypothyroidism is identified as suboptimal thyroid hormonal production associated with mild TSH [thyroid stimulating hormone] elevation. Though several non-thyroidal illness in the later stages, medications and dietary supplements may resemble SCH [subclinical-hypothyroidism], but mild persistent subnormal thyroidal pathologies are usually termed as SCH. This review briefly describes the various cardiovascular risk associations with subclinicalhypothyroidism and attempts to provide an insight into the risk and benefit association, which a patient faces once treated for SCH

Classical homocystinuria in a juvenile patient

Classical homocystinuria, also known as cystathionine beta synthase deficiency, is a rare disorder of methionine metabolism, leading to an abnormal accumulation of homocysteine and its metabolites in blood and urine. A young child with homocystinuria is discussed, who presented with behavioral abnormalities, involuntary movement, mental retardation, and decreased vision since birth. The diagnosis of homocystinuria was not made at initial presentation. Subtle phenotypic features with developmental delay and MRI brain finding of bilateral medially dislocated lens, eventually provided the first indication at five years of age. Laboratory screening with plasma amino acid profile by ion exchange chromatography [IEC] showed elevated homocystine and methionine, and low cystine in plasma in the absence of vitamin B12, and folate deficiency; giving the diagnosis of classical homocysteinuria

Association of metabolic risks with subclinical hypothyroidism: a cross-sectional analysis

Objective: To compare lipid parameters, HbA1c, uric acid and albumin creatinine ratio [UACR] among subjects having euthyroidism, Sub-Clinical Hypothyroidism [SCH] and overt hypothyroidism

Methods: This comparative cross-sectional analysis was carried out from Dec-2015 to Oct-2016 in collaboration between PNS HAFEEZ hospital and department of chemical pathology and endocrinology, Armed Forces Institute of Pathology, Rawalpindi. Biochemical parameters including lipid indices, HbA1c and UACR were compared between euthyroidism [TSH: 0.5 to 4.0 mIU/L, n=163], subclinical hypothyroidism [TSH: 4.0 to 10 mIU/L, n=16] and overt hypothyroidism [TSH:>/= 10.0 mIU/L, n=9]

Results: LDL-cholesterol, non-HDL-cholesterol and UACR results were as: [[Euthyroid: 2.66 +/- 0.73], [SCH: 2.68 +/- 0.51] and [Overt hypothyroidism: 3.23 +/- 0.59], p-value=0.063], [[Euthyroid: 3.49 +/- 0.64], [SCH: 3.35 +/- 0.59] and [Overt hypothyroidism: 4.01 +/- 0.30], p-value=0.033] and [[Euthyroid: 2.48 [95% CI: 1.63-3.33]], [SCH: 2.27 [95% CI: 0.37-4.90]] and [Overt hypothyroidism: 14.95 [95% CI: 10.71-19.14]], [p-value< 0.001]]. Results for total cholesterol, triglycerides and HDL-cholesterol though increased in overt hypothyroid group were not found to be statistically significant

Conclusion: LDL-cholesterol, non-HDL-cholesterol and UACR increased from euthyroid subjects to overt hypothyroidism group. However, these changes were found to be more subtle in the subclinical hypothyroid subjects than cases with overt hypothyroidism

determination of medians of biochemical maternal serum markers in healthy women giving birth to normal babies

Objective: To determine median values of biochemical maternal serum markers during second trimester maternal screening to rule out chromosomal anomaly, Down syndrome. Study Design: Cross sectional study. Place and Duration of Study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology [AFIP], from Nov 2016 to May 2017

Patients and Methods: Non-probability consecutive sampling technique was used. All healthy pregnant women with single pregnancy were included. As non-parametric statistics was used, the sample size was collected to be 155. Blood sample for serum human chorionic gonadotropin [HCG] was analyzed on random access immulite 2000, alpha-fetoprotein [AFP] was analyzed on ADVIA Centaur, unconjugated estriol [uE3] and Inhibin A measured by Enzyme-Linked Immunosorbent Assay [ELISA] method by PR 4100 Micro plate Reader

Results: Total 155 women were enrolled in this study. Mean maternal age was 33.46 +/- 2.35 years and mean maternal body weight was 54.98 +/- 2.88 kg. Median value of quadruple markers, calculated from 15-18[th] week of gestation, was used for calculation of multiple of median [MoM] for screening of trisomy 21 in this gestational age. Median values at 15 week of gestation: hCG 36650 mIU/ml, AFP 23.3 IU/ml, uE3 3.5 nmol/l, Inh A 198 ng/l, at 16 week of gestation: hCG 29050 mIU/ml, AFP 35.4 IU/ml, uE3 4.1 nmol/l, Inhibin-A 179 ng/l; at 17 week of gestation: hCG 28450 mIU/ml, AFP 36.0 IU/ml, uE3 6.7 nmol/l, Inhibin-A 175 ng/l and at 18 week of gestation: HCG 25200 mIU/ml, AFP 38.2 IU/ml, uE3 8.2 nmol/l, Inhibin-A 190 ng/l

Conclusion: In this study we were able to get median values of quadruple markers for regional population, which will be used in future to calculate MoM for the screening purpose of Down syndrome. It will help to rule out Down syndrome by non-invasive test and at early stage of pregnancy

Bilirubin interference in plasma amino acid analysis by ion exchange chromatography

Objective: To evaluate the effect of bilirubin interference on plasma amino acid analysis by Ion Exchange Chromatography [IEC]

Study Design: Cross-sectional [method validation] study

Place and Duration of Study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi from August 2016 to July 2017

Methodology: Twenty non-icteric samples from paediatric patients were collected in lithium heparin tubes and analysed for amino acids on IEC-based BiochromeR 30+ Analyzer [Harvard Biosciences UK]. Baseline bilirubin levels were noted. Samples were spiked with neonatal bilirubin standard with concentration of 488.4 Mu mol/L [SpinreactR-Spain] at final concentrations of 50, 150 and 230 Mu mol/L and re-analysed for amino acids at these three concentrations

Results: Among the 20 selected patients with normal amino acid profiles, 12 [60%] were males. Majority [55%] were in age group of 1-5 years. Significant difference was observed for Arginine [p = 0.01], Histidine [p = 0.001], Isoleucine [p = 0.01], Leucine [p = 0.007], Lysine [p = 0.005], Ornithine [p = 0.03] and Phenylalanine [p = 0.02]. Mean rank of these amino acids showed decreasing trend with the increase of bilirubin concentration, and pronounced interference was identified at bilirubin level of 50 Mu mol/L. No difference was observed for alanine, citrulline, glutamic acid, glycine, methionine, proline, threonine, tyrosine, asparagine, aspartic acid, cystine, valine and tryptophan

Conclusion: Bilirubin significantly interferes with certain amino acid levels when analysis is carried out by ion exchange chromatography. A close follow-up of such patients with other biochemical tests and a repeat amino acid analysis, after jaundice is settled, is recommended to confidently rule out any possible inherited metabolic disorder in these patients

novel clinico-biochemical score for screening of inherited metabolic diseases in children

Objective: to evaluate a novel clinico-biochemical score for screening of inherited metabolic diseases [IMDs] in children in our setup

Study Design: descriptive analytical study

Place and Duration of Study: department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from August 2016 to August 2017

Methodology: clinical data, preliminary biochemical investigations, plasma amino acid [PAA] and organic acid profiles [where indicated] of 354 children, aged <1 year to 12 years, referred to the study place for evaluation of suspected inherited metabolic diseases, was collected and evaluated. A clinico-biochemical score card named Rawalpindi Inherited Metabolic Diseases Score [RISc] was devised, on a scale from 1 to 10, incorporating 5 clinical and 5 important biochemical findings, and each variable was assigned a score, based on its relative frequency/risk. Each case was then assigned the RISc score and evaluated for presence or absence of any inherited metabolic disease, based on the score. This score was validated keeping plasma amino acids and organic acid profiles [in selected cases] as reference standard

Results: patients were divided into three groups, based on RISc score as low RISc [0.5-2.5], medium RISc [3.0-5.5] and high RISc [6-10]. A total of 354 cases reported in 2016 and 2017 and 33 [9.3%] were diagnosed to be having IMDs. One [3.0%] patient from low RISc, four [12.1%] from medium RISc, and 28 [84.8%] from high RISc group were found to test positive for any one IMD. High RISc group had a statistically significant higher IMD rate than the other two groups [p<0.001]. Specificity, sensitivity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value and accuracy were 93%, 85%, 11.8, 0.16, 55%, 98% and 90%, respectively

Conclusion: the cost effective RISc, based on clinical data and preliminary biochemical investigations, is highly accurate in diagnosing IMDs in cost restrained setups. It is strongly suggested that the initial screening for suspected IMDs and decision for advanced laboratory testing be carried out, based on the RISc card presented in the study

Association of hypomagnesemia with hyperglycemia and its renal complication in outpatients

Objective: To evaluate the association of hypomagnesemia with hyperglycemia and its renal complication in outpatients

Study Design: Case control study

Place and Duration of Study: Department of chemical pathology and endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from October 2014 to July 2015

Material and Methods: Adults of either gender aged 20 years and above comprising 63 subjects with hyperglycemia and 63 controls with normoglycemia were consecutively inducted in the study. Patients with malabsorption, thyroid dysfunction or adrenal dysfunction, renal impairment, taking mineral supplement, pregnancy, lactation and any acute illness were excluded from the study. Fasting plasma glucose [FPG] and serum magnesium [Mg] level were measured on ADVIA 1800 siemens clinical chemistry auto-analyzer with hexokinase and xylidyl blue methods, respectively. Urine albumin was analyzed by Immunoturbidimetric method and urine creatinine was measured by the Jaffé kinetic assay on same analyzer. Albumin/creatinine ratio [ACR] was calculated. Pearson correlation coefficient "r" was calculated for serum Mg with FPG and ACR. Mean serum Mg levels in hyperglycemic and normoglycemic groups were compared using in dependent sample "t" test. Frequency of hypomagnesemia [serum magnesium

Results: Serum Mg has significant inverse correlation with FPG [r=-0.543, p=0.001] and ACR [r=-0.474; p=0.001].Mean serum Mg was 0.78 mmol/l in hyperglycemics and 0.88 mmol/l in normoglycemics [p=0.001]. The frequency of hypomagnesemia in subjects with type 2 Diabetes Mellitus [T2DM] was found to be 18.8% while no subject with pre-diabetes and normoglycemia had hypomagnesemia

Conclusion: Subjects with hyperglycemia had significantly lower mean serum Mg levels compared with healthy counterparts. Hypomagnesemia was also associated with poor glycemic control and diabetic nephropathy

Evaluation of dyslipidaemia in type 2 diabetes mellitus patients

Objective: This study is aimed to evaluate the correlation of raised levels of Non-high-density lipoprotein cholesterol [Non-HDL-C] in Type 2 Diabetic patients

Study design: Cross sectional study

Place and duration of study: Department of Chemical Pathology and Endocrinology, PNS SHIFA hospitalKarachi, from 20.5.2014 to 20.11.2014

Materials and Methods: Diabetic patients between 30-70 years age, of either gender and having diabetes for more than five years were included in the study. Patients with co-existing Hypothyroidism, Chronic renal failure, Nephrotic syndrome, Familial hypercholesterolaemic syndromes, already on lipid lowering drugs, anti-hypertensive drugs, using beta blockers or thiazide diuretics, obese patients with BMI greater than 30 and those using alcohol were excluded. Blood samples after overnight 10 hours fasting were taken for fasting plasma glucose, serum total cholesterol and HDL-cholesterol

Results: The average age of the patients was 48.75 +/- 11.02 years. Out of 232 patients, there were 124[53.45%] males and 108[46.55%] females. Raised levels of non-high-density lipoprotein cholesterol [>3.33 mmol/L] in type 2diabetic patients was observed in 80.6% [187/232] cases

Conclusion: Raised level of non-high-density lipoprotein cholesterol in diabetes mellitus patients is reasonably high. Appropriate therapeutic interventions should be carried out on basis of simple test such as non-HDL-C in type2 diabetics to avoid risk of cardiovascular, cerebrovascular and renal disease complications, thereby reducing mortality and morbidity in these patients

Determination of mean clycated aemoglobin in healthy adults of a local population

Objective: To determine the mean hemoglobin HbA1C levels of disease-free adults in a local population and its optimum cutoff for the diagnosis of diabetes

Study Design: Cross-sectional study

Place and Duration of Study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from January to September 2015

Methodology: Healthy subjects aged 18 years and above of either gender were recruited from local population. Pregnant ladies and individuals with known diabetes, chronic kidney disease, chronic liver disease, congestive cardiac failure, anemia, hemoglobinopathies, mental illness and individuals on glucocorticoid therapy were excluded. Fasting plasma glucose [FPG] or 2-hour plasma glucose [2-h PG] was analyzed using hexokinase methodology and glycated hemoglobin [Hb A1C] was also analyzed using turbidimetric inhibition immunoassay technique. Receiver operating characteristic [ROC] curves were plotted. Differences among the groups were tested by one-way ANOVA, and p <0.05 was considered statistically significant

Results: Among 558 subjects, 88.8% [496] were normoglycaemic [NG], 5.7% [32] were with impaired glucose fasting [IFG], and 5.4% [30] were diagnosed with diabetes mellitus [DM]. A1C was 5.00 +/-0.44% in NG and 6.28 +/-1.16% in diabetics. FPG in NG was 4.55 +/-0.95 mmol/L and in diabetics was 8.28 +/-1.78 mmol/L. The optimal HbA1C cutoff value for diagnosis of DM was at 6.05% [AUC 0.827 95% CI 0.732 to 0.923, p ²0.05 with its sensitivity of 53.3% and specificity of 98.5%. However, HbA1C showed suboptimal sensitivity and specificity for prediabetes

Conclusion: The mean HbAIC and cutoff point for diabetes in the study population is 5.07 +/-0.58% and 6.05%, respectively [AUC 0.827, 95% CI: 0.732 to 0.923, p<0.001] with 53.3% sensitivity and 98.5% specificity

Insulin resistance and glucose levels in subjects with subclinical hypothyroidism

Objective: To compare insulin resistance and glycemic indicators among subjects with euthyroidism and subclinical hypothyroidism

Study Design: Comparative cross-sectional study

Place and Duration of Study: Department of Pathology and Medicine, PNS Hafeez, Islamabad, in collaboration with the Department of Chemical Pathology and Endocrinology at the Armed Forces Institute of Pathology [AFIP], Rawalpindi, from December 2015 to September 2016

Methodology: Subjects referred for executive screening of apparently healthy population [without any known history of diabetes, hypertension, heart disease or other chronic ailments], were included. Subjects were grouped as euthyroidism and subclinical hypothyroidism

Results: Median [IQR] insulin resistance indices including fasting insulin and Homeostasis Model Assessment for Insulin Resistance in subjects with group-1 [n=176, 87%, Thyroid Stimulating Hormone: 0.5 - 3.5 mlU/L] and group-2 [n=26, 13%, Thyroid Stimulating Hormone: 3.51 -15 mlU/L] were 7.6 [6.70] vs. 11.4 [13.72, p=0.040] and 1.77 [1.79] vs. 2.8 [3.07, p=0.071]

The median differences for fasting plasma glucose were 5.0 [1.0] in group-1 vs. 5.0 [1.47] for Group-2 [p=0.618], and glycated hemoglobin was 5.60 [1.1] vs. 5.60 [1.7, p=0.824]. Homeostasis Model Assessment for beta sensitivity index in paradox showed slightly higher values for group-2 [median [IQR] 86.67 [92.94]] than group-1 [111.6 [189.64, p= 0.040]]

Conclusion: Measures of insulin resistance including Homeostasis Model Assessment for Insulin Resistance and fasting insulin levels were significantly different between subjects with euthyroidism and having subclinical hypothyroidism

Accuracy of non-fasting lipid profile for the assessment of lipoprotein coronary risk

Objective: To determine the diagnostic accuracy of non-fasting lipid profile in the diagnosis of hyperlipidemia, taking fasting lipid profile as gold standard, in adult population

Study Design: Cross-sectional validation study

Place and Duration of Study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from July to December 2014

Methodology: One hundred seventy-five adult patients coming for fasting lipid profile were included; their non-fasting samples were taken on the next day. Patients on anti-cholesterol treatment and indoor patients were excluded. Total cholesterol [TC], high density lipoprotein-cholestrol [HDL-C], and triglycerides were measured by direct enzymatic colorimetric method by Modular p-800[registered]. Low density lipoprotein-cholesterol [LDL-C] was calculated by Friedewald's formula, but when triglyceride was greater than 4.5 mmol/l, then LDL-C was measured directly by homogenous enzymatic colorimetric method. Non-HDL-C was calculated by simple equation, i.e. TC-HDL-C

Results: Non-fasting lipid profile had 93% specificity, 51% sensitivity, 94% positive predictive value and 49% negative predictive value; and 65% accuracy with 7.28 positive likelihood ratio and 0.52 negative likelihood ratio. Non-fasting TC and non-HDL-C were significantly higher than fasting TC and non-HDL-C by mean difference of 0.2 mmol/l each with p=0.001 and p=0.004, respectively. Fasting and non fasting HDL-C are comparable to each other with mean difference of 0.01 mmol/l [p=0.745]. Receiver operating curve [ROC] of non-fasting non-HDL-C showed 0.804 [95%CI [0.738-0.870], [p=0.000] area under the curve [AUC] indicating that it was a significant test for ruling out hyperlipidemia. Bland-Altmann plot showed a significant difference between non-fasting, non-HDL-C and fasting LDL-C and non-fasting, non-HDL-C -0.087540 with bias -0.00109; therefore, these cannot be alternative to each other

Conclusion: Diagnostic accuracy of non-fasting lipid profile was found significantly higher than fasting lipid profile [p=0.004] for the assessment of lipoprotein coronary risk on the basis of non-HDL-C, which seemed to be significant test for ruling out hyperlipidemia

Diagnostic accuracy of serum iron and total iron binding capacity [TIBC] in iron deficiency state

Objective: To determine the diagnostic accuracy of serum iron and total iron binding capacity [TIBC] in detection of iron deficiency

Study Design: Descriptive, analytical study

Place and Duration of Study: Department of Chemical Pathology and Endocrinology, from January 2013 to October 2015

Methodology: Data of 1,815 patients with results of serum iron, TIBC and ferritin from January 2013 to October 2015 was retrieved from Laboratory information System [LIMS] of AFIP. Diagnostic Accuracy Studies [STARD] guidelines were followed. Subjects of either gender, aged 1 - 68 years were included. Cases with raised serum ferritin levels [male > 336 ng/ml, female > 307 ng/ml] were excluded. Serum Ferritin was taken as gold standard with specificity of 99% and sensitivity of 80% at concentration of 30 ng/ml. Transferrin saturation was determined by dividing serum iron by TIBC and multiplying by 100

Results: Out of 1,815 subjects, 931 [51.29%] were males and 884 [48.71%] were females. The median age of the patients were 29.1 years [Inter-quartile range, IQR 19.1]. Taking ferritin as gold standard, the sensitivity and specificity of serum iron was 63.5% and 38.6%, respectively; while that of TIBC was 64.5 % and 42.8%, respectively. Ferritin showed poor correlation with iron, TIBC and transferrin saturation

Conclusion: Serum iron and TIBC give no additional information in the diagnosis of iron deficiency anemia and these tests are redundant for the diagnosis of iron deficiency state, if serum ferritin is available

Decreased serum 25-hydroxycalciferol levels in pre-diabetic adults

Objective: To determine the serum 25-hydroxycalciferol levels [25[OH]D] in adults with pre-diabetes and normoglycaemia to examine a possible association of vitamin D deficiency with pre-diabetes

Study Design: Case control study

Place and Duration of Study: Armed Forces Institute of Pathology, Rawalpindi, from November 2012 to July 2013

Methodology: A total of 272 adults including 136 pre-diabetics and 136 normoglycaemics of either gender aged 20 years and above were consecutively inducted. Patients with diabetes mellitus, pregnancy, rickets and osteomalacia, ischemic heart disease, chronic kidney disease and chronic liver disease were excluded. Fasting Plasma Glucose [FPG] was estimated with hexokinase method on Modular p800 Roche chemistry analyzer while serum 25[OH]D was measured on Diasorin Liaison immunoassay analyzer using the chemiluminescent technique. Mean 25[OH]D levels in pre-diabetic and normoglycaemic groups were compared using Mann-Whitney U test. Spearman's correlation coefficient 'r[s]' was determined between serum 25[OH]D and FPG. Odds ratio for vitamin D deficiency was also calculated

Results: Mean serum 25[OH]D level was low in pre-diabetics [23.2 nmol/L] as compared to normoglycaemics [29 nmol/L; p=0.001]. Serum 25[OH]D level had inverse correlation with FPG [r[s] = -0.448, p=0.000]. There was also significant association of vitamin D deficiency with pre-diabetes compared with normoglycaemia [OR: 2.21, p= 0.016; 95% CI: 1.15-4.27]

Conclusion: Vitamin D deficiency with pre-diabetes suggested that vitamin D may have an important role in pathogenesis of pre-diabetes

Metabolic syndrome in patients with schizophrenia

OBJECTIVE: To determine frequency of metabolic syndrome in patients with Schizophrenia, in a tertiary care armed forces setup

STUDY DESIGN: Cross sectional study

PLACE AND DURATION: Department of Psychiatry, PNS SHIFA, Karachi from October 2009 to April 2010

MATERIALS AND METHODS: Fifty six patients with Schizophrenia reporting for management in PNS SHIFA were enrolled as subjects. Demographic variables and other confounding variables were recorded in a structured Performa, Blood Pressure [BP] and Waist Circumference [WC] were measured while Fasting Plasma Glucose [FPG], Triglycerides [TAG] and HDL-Cholesterol [HDL-C] levels were estimated by routine methods in laboratory with quality assurance

RESULTS: More than half i.e.30 [53.6%] of subjects had Metabolic Syndrome [MS] as per ATP IIIA criteria. Further 25% [n=14]of subjects were positive for two components of MS. Low HDL-C levels were most prevalent component followed by hyperglycaemia, hypertriglyceridemia and increased WC while hypertension was least common component

CONCLUSION: Metabolic Syndrome and its various components are frequently co morbidity in patients with Schizophrenia

Antibiotic sensitivity patterns of staphylococcal skin infections

To determine the current sensitivity pattern against staphylococci found in skin and soft tissue infections. Patients were enrolled from OPD of Dermatology Department, PNS Shifa Hospital, Karachi. All the patients with skin infections showing growth of Staphylococcus aureus on culture medium were selected. After informed consent, swab specimens were collected under aseptic measures from skin lesions for microbial analysis and sensitivity pattern. Among skin infections, furunculosis was found most common, comprising of 45.7% [n=43], cellulitis 15.0% [n=14], ecthyma 8.5% [n=8], erysipelas 8.5% [n=8] and impetigo 22.3% [n=21]. According to drug sensitivity patterns, vancomycin was found sensitive in 100%, linezolid 98.9%, mupirocin 96.8%, rifampicin 95.7%, chloramphenicol 94.7%, clindamycin 86.2%, amikacin 84%, moxifloxacin 83%, fusidic acid 79.8%, gentamicin 76.6%, oxacillin 69.1%, ciprofloxacin 68.1%, amoxicillin-clavulanic acid 62.8%, erythromycin 60.6% and trimethoprimsulphamethaxazole 57.4% of cases Vancomycin, linezolid, rifampicin, clindamycin, moxifloxacin and chloramphenicol showed highest efficacy in this study. However, clinical studies are required to confirm in vivo efficacy and side effect profile of these drugs

Evaluation of strategies to increase students involvement for improving interactive lectures in chemical pathology

To evaluate students perspective on effectiveness of various strategies employed to increase their involvement in an interactive lecture. Case study with pragmatic research paradigm. College of Physicians and Surgeons [CPSP] Karachi and Regional Centre Islamabad, Pakistan from Jan 2012 to Jan 2014. Three hundred and three post graduate students attending preparatory courses [82[nd] to 87[th] Basic Medical Sciences] for Fellow College of Physicians and Surgeons [FCPS] Part I were selected for the study. Teaching strategies like multiple choose questions [MCQs], flash cards as audience response system [ARS] and purposefully designed hand-outs were used. Questionnaire based on Likert's Scale [quantitative] and video recorded focus group discussion [FGDs] with small groups of students [qualitative] were used for evaluation of the teaching strategies. Mostly females [78%] with mean age of 29 years from 15 different medical and dental specialties were included in the study after obtaining their informed written consent. Average total score was found to be 25.71[95% CI: 25.40 to 26.02] out of maximum possible score of 30 [if all the six questions were strongly agreed to]. Liking of the students as determined from feedback forms was for Flash Cards as ARS [89%], MCQs [88%] and hand-outs [85%] while content coverage received poorest liking [79%]. Similar themes were found in the content analysis of FGDs. There was a significant increase in the students liking from 82[nd] course [Jan 2012] to 88[th] Course [Jan 2014]. Post-graduate students preparing for FCPS part I examination highly approved the strategies to increase effectiveness of lectures in the preparatory courses

Vitamin D status and diabetes mellitus

Introduction: Diabetes mellitus is a worldwide epidemic, similarly low Vitamin D levels constitutes a largely unrecognized epidemic in many populations. There is no study in our country to document the association between these two common metabolic disorders

Objective: To assess the degree of correlation between vitamin D status and various categories of hyperglycaemia in a Pakistani population. Study Design: Descriptive cross sectional study. Place and Period of Study: Department of Pathology, PNS SHIFA Hospital, Karachi; Jan 2013 to Aug 2013. Glucose levels were measured in eight six patients divided on the basis of their 25- hydroxyvitamin D3 [25OHD] levels in three groups, normal [>31 ng/ml], insufficient [20-31ng/ml] and deficient [<20ng /ml]. 25OHD was measured by electrochemiluminescence using Roche Elecsys® Systems while glucose was estimated by routine methods on Roche Hitachi® Autoanalyser

Results: Vitamin D levels were inversely correlated with plasma glucose levels [r=0.38; p <0.01] with an Odd Ratio of 3.59 [95%confidence interval 1.29 to 8.70]. Fasting plasma glucose was significantly higher in vitamin D deficient patients as compared to patients with normal vitamin D status [p <0.05]

Conclusions: Vitamin D deficiency is negatively associated with plasma glucose levels

Diabetes mellitus prediction; Serum lipids, ALT and fasting blood glucose: using serum lipids and ALT

The rapid change in lifestyles and dietary has led to a pandemic of diabetes mellitus. The diagnosis of diabetes mellitus sometimes requires 2 hr OGTT sampling. Recent evidence has shown that there are lipid related abnormalities associated with diabetes mellitus, so a consideration comes in fortheir utilization as a marker to support diabetes mellitus. [1] To correlate serum total cholesterol, triglycerides and ALT with fasting blood glucose [2]. To predict diagnosis of diabetes mellitus using above serum markers. Cross-sectional analysis, descriptive study. This study was carried out between Mar-2010 to Jan-2011 at the department of pathology, PNS RAHAT in collaboration with PNS SHIFA. A total of 251 subjects were screened for presence of glucose dysregulation. Based upon the results of fasting blood glucose, subjects were grouped as having normal glucose tolerance [NGT], impaired fasting glucose [IFG], and newly diagnosed diabetes mellitus [NDDM]. A comparison of lipids including triglycerides, total cholesterol and alanine aminotransferase [ALT] were made in the above groups to measure the differences between the above mentioned three groups. ALT, triglyceride and total cholesterol were correlated with results of fasting blood glucose through pearson's correlation. Later the performance of different cut-offs of triglycerides, total cholesterol and two mathematical models [[Factor-l=FBG [mmol/L] + triglycerides [mmol/L]] and [Factor-ll=FBG [mmol/L] + triglycerides [mmol/L] + total cholesterol [mmol/L]]] were evaluated for detecting diabetes mellitus against the gold standard 2 hr OGTT in 71 subjects. The results of triglycerides, total cholesterol and serum ALT between the three groups were as: [[Triglycerides: NGT =1.91, IFG =2, 10, NDDM= 2.75, p=0.003] [total cholesterol: NGT=5.03, IFG=5.19, NDDM=5.74, p=0.056] [ALT:NGT=28.47, IFG=27.95, NDDM=25.78, p=0.846]]. Most correlation was found between serum triglycerides and fasting blood glucose [r2=0.235, p<0.001]; while serum total cholesterol and ALT showed lesser correlations [[total cholesterol:r2= 0.172, P=0.007], [ALT:r2= 0.010, p= 0.877]]. While triglycerides demonstrated superiority in terms of sensitivity to total cholesterol for detection of diabetes mellitus, the factors incorporating lipids and glucose had the highest overall diagnostic efficiency. Triglycerides and total cholesterol levels rise from normoglycemic individuals to subjects having impaired fasting glucose and newly diagnosed diabetics. The inclusion of triglycerides and total cholesterol for diagnosis of diabetes mellitus improves the chances of for detection of diabetes mellitus

Improvement in the pattern of advice of investigations following rationalization campaign

To assess the magnitude of change in advising pattern of laboratory and radiological investigations during and after campaign emphasizing rational use of these tests. Comparative cross sectional study. Combined Military Hospital Peshawar, Twenty seven months. The laboratory investigation analysis were Blood Glucose, Thyroid Function Tests, Liver Function Tests [LFT], Renal Function Tests [RFT] and Cardiac Markers and radiological tests were X-Rays Chest, Skull, Wrist and Plain Abdomen, Obstetric Ultra Sound [USG] and CT Scan. The awareness was done by Lectures, handouts, feedback advice on test reports and personal communications to the Medical Officers, Nursing Officers and Paramedical Staff. The data was analyzed through Quarterly Returns, records of laboratory and radiology retrieved from Hospital Information System and departmental registers. In some laboratory investigations there was a significant improvement in the advisory pattern e.g. blood glucose fasting instead of random, ALT instead of whole LFT, electrolytes not included in every RFT and abolishing of AST and LDH from cardiac marker profile and TSH only as screening test. In Radiology there was improvement in the rationality of X-Ray chest, X-Ray skull, X-Rays wrist and obstetric USG. CT scan data could not be compared because CT Scan equipment became out of order during the study. There was also reduction in expenses incurred on irrational investigations. A dynamic ongoing process of awareness and realization campaign for medical professionals is required in any public sector medical institute for cultivating a culture of rational use of investigations

Pattern of injuries inflicted on troops fighting, on the western front

To determine the pattern of fatal and non fatal injuries in soldiers and officers during the present war on Western front. Descriptive study with partly retrospective data collection. The study was carried out at Combined Military Hospital [CMH] Peshawar, the tertiary care centre for Pakistan Armed Forces serving FATA and NWFP from March 2004 to May 2009. Data of non-fatal injuries was collected by noting down the wounds inflicted on injured soldiers and officers evacuated from forward areas while the record of non-fatal injuries was noted from the hospital papers prepared for each patient. Due to reasons of confidentiality the analyses is based on percentages only, while actual figures can be provided by the authors on appropriate security cleared requests. The Lethality Index [LI] of wounds, calculated by dividing the fatal injuries by the total injuries, was 18% during these six years. Out of the total fatal injuries in all six years highest number occurred in 2008 [40%] while LI was highest in 2005 [25%]. Only a small number of patients [1.86%], who were evacuated alive, died in the hospital. Fifty one percent soldiers received multiple [>two] fatal injuries. Head [46%] and Chest [44%] were the commonest sites of fatal injuries while limbs were the commonest sites of non-fatal injuries. Gun shot wounds were the commonest [68%] mode of fatal and non-fatal injuries. Head and chest injuries are the commonest sites of fatal injuries, while limbs injuries constituted the major portion of the non-fatal injuries indicating potential areas in need of improved protective